Epilepsy

=Definition.=—A chronic affection of the nervous system, characterized

by attacks of unconsciousness, which are usually accompanied by general

convulsions. When there is merely a momentary loss of consciousness it

is called =petit mal=. Loss of consciousness with convulsions is called

=grand mal=. When the convulsion is localized, with or without loss of

consciousness, it is called =Jacksonian epilepsy=. Certain cases of

temporary loss of consciousness are termed =psychic epilepsy=.

=Etiology.=—Epilepsy usually begins before puberty, and comparatively

seldom after the twenty-fifth year. Males suffer somewhat more

frequently than females. Heredity predisposes to the disease to some

extent, but probably not so greatly as many writers would claim.

Neuroses, as insanity and hysteria, and intermarriage of relatives,

are important elements to consider. When epilepsy is inherited, it is

almost always due to some morbid state of the nervous system. Other

predispositions to the disease may be caused from defective general

development of the brain, from impairment of the general health, and

from an exhausted nervous system.

Many =exciting causes= may be found: mental emotion, fright, excitement

and anxiety; blows and injuries to the head; infectious diseases;

syphilis; alcoholism; masturbation; ocular and aural irritation;

disturbed and delayed menstruation. Epilepsy may be excited by reflex

convulsions from intestinal worms, gastric irritation, etc. Also

thickening of the membranes of the brain, pressure from a tumor at the

periphery, uterine diseases and many other sources of irritation may be

found, that are the exciting causes of epilepsy.

Important exciting causes of epilepsy are, undoubtedly in many cases,

due to =lesions= of the =vertebræ= and =ribs= especially the vertebræ

of the cervical region, although in some cases the lesion is in the

lower splanchnic region or in the ribs (chiefly from the fourth to the

eighth). These lesions to the spinal tissues disturb the nutrition

to the vasomotor nerves. If the real seat of the disease is in the

cerebral cortex and the medulla, the cervical lesion, and in fact other

lesions, could readily affect the nerve force and circulation to and

from these regions. The vertebral artery circulation, where a cervical

lesion exists, may be involved and affect the brain. In cases where

lesions of the vertebræ and ribs exist in the upper and middle dorsal

region, the vasomotor innervation to the brain may be involved, for in

this region the vasomotor nerves to the cranium, etc., pass from the

cord into the sympathetics. Birth injuries may affect the brain tissue,

through cervical lesions, hemorrhages and asphyxiation.

Conklin attaches considerable importance to stasis of the sigmoid and

ascending colon. Lesions involving this region may result in toxins

entering the blood and affecting nervous tissue.

To illustrate a specific exciting lesion, the following is interesting.

The case was one of epilepsy that was evidently caused by a dislocated

right fifth rib. By producing an irritation in the region of this

rib, so that the lesion was increased, the patient could be made to

immediately suffer from an attack of epilepsy. By resetting the rib, at

once the sufferer would be entirely relieved. The case was cured after

three months’ treatment, the chief work being to keep the rib in place.

Rarely a subdislocated innominate bone, or some lesion remote from the

brain, is located and found to be causing epilepsy. Important lesions

in most cases will be readily located in the cervical region. Booth

reports: “I have records of seven fairly defined cases of epilepsy—such

as have been so pronounced by M. D.’s. I find in all of them =marked

lesions= in the =upper cervical= and in most of the cases the occiput

is posterior upon the atlas or twisted. In all cases there was a

thickening of the soft tissues, especially in the upper cervical. The

lower cervical was also much involved but not so noticeably. All of the

cases also presented marked disturbances in the upper dorsal; most were

decidedly anterior, and one very posterior. One was almost a confirmed

drunkard; notwithstanding the fact, he recovered to such an extent that

he went to work, and I understand has been holding his position for

more than three years. He had had to give up his work entirely. One

was a hopeless case in every particular and did not seem to receive

any benefit from the treatment. I think it was entirely beyond help

from any source. The others responded very well and the results were

definite and decided. The length of treatment in successful cases

ranges from about five weeks to a little over a year. But those that

were treated the greater length of time were not treated continuously.”

After one convulsion has occurred, others readily occur, owing to

the proneness to changes in the nerve centers. Very little is known

as to the pathology of this disease. Convulsions may be caused from

irritation of both the cortex cerebri and the medulla oblongata. From

a study of the character of the auræ, one is led to believe that

there is a disturbance, in most cases, in the centers of the cerebral

cortex; and that the lesions so generally found along the spinal column

are the true exciting causes of the disease. Perhaps in a few cases

the irritation may be to the medulla reflexly. The lesions found on

osteopathic examination may act reflexly, as has been stated, upon the

centers in the brain and excite them; or the circulation is deranged,

and consequently the nutrition to the brain and meninges, by vasomotor

control and the vertebral vessels, is impaired.

The splanchnic area and the cervical region should always receive

special attention. This in conjunction with all possible reflex

sources, and, not least, the general health, restoring a stable nervous

system if possible, are of greatest importance.

As a rule, =pathological= lesions are not found. To the naked eye the

appearance of the nerve centers is largely that of healthy organs. The

changes revealed by the microscope are most probably those of secondary

origin. Recent experiments seem to show that the motor zone of the

cortex is affected.

=Symptoms.=—These will be considered under the three varieties, known

as grand mal, petit mal and Jacksonian. =Grand mal.=—In most cases the

seizure is preceded by a pronounced sensation known as the =aura=. This

differs greatly in various individuals. It may begin in a finger or

toe and rise until it involves the head, when the patient screams and

falls to the floor unconscious. In other cases the sensation may start

from other parts of the body, as the epigastric region, where it may

simply be a slight discomfort; or other sensations may be felt, as that

of a ball rising from the stomach. The aura may start from any part of

the body as a numbness, tingling, chilliness, etc., and may, also, be

manifested through the optic, olfactory, auditory and gustatory nerves,

by flashes, smells, sounds and tastes. “Intellectual auræ” may also be

manifested. Some form of auræ is met with in nearly one-half the cases

of epilepsy. Others lose consciousness so early that the patient is not

aware of the onset. In cases not attacked suddenly and not preceded

by an aura, a prolonged prodrome may be present for several hours or

a day. The patient may feel irritable, dizzy or dispirited. Or he may

be quiet and calmly await the attack. In a few cases certain movements

may precede an attack, as running rapidly forward in a circle, or

standing on the toes and rotating rapidly. The attack proper is sudden.

The patient falls with a peculiar cry. The =convulsion= or fit may be

divided into =three stages=, that of =tonic= spasm, of =clonic= spasm

and of =coma=.

The =tonic spasm= succeeds the epileptic cry; there are loss of

consciousness, pallor of the face and the contraction of pupils. The

body assumes a position of tetanic rigidity, the head is retracted and

rotated, and the spine curved, owing to an unequal affection of the

muscles of the two sides. The jaws are fixed, the arms are flexed at

the elbow, the hands at the wrist, and the fingers are clinched. The

legs and feet are extended. The muscles of the chest are involved and

respiration is suspended. This stage lasts a few seconds. The =clonic

spasm= follows the tonic spasm. The muscular contractions become

intermittent. From slight vibratory motions, the intermittent muscular

contraction becomes general. The arms and legs are thrown about

violently, the muscles of the face are distorted, the eyes rolled, and

the lips open and close. The muscles of the jaw contract violently

and the tongue is apt to be bitten. The pupils are dilated, the face

cyanosed (though at first the face is pale and pupils contracted) and

blood-streaked, frothy saliva pours from the mouth. The feces and urine

may be discharged involuntarily. The temperature rises about one degree

F. This stage lasts about one or two minutes. The period of =coma= may

last from a few minutes to several hours. Usually if left alone, the

patient will awaken after a few hours. In a few cases mental confusion

follows the waking. During the stage of coma, the face is congested

but not cyanotic. The muscles are relaxed and the breathing is noisy.

Epileptic attacks during sleep, =nocturnal epilepsy=, are not rare.

This may continue for some time without the patient being aware of it.

=Petit Mal.=—In this variety of epilepsy, convulsions are absent. The

seizure consists of momentary unconsciousness with fixed, staring eyes,

dilated pupils and rarely any twitching of the muscles. After the

attack the patient resumes his work. There may be attacks of vertigo,

without unconsciousness, and the patient may fall. In a few instance

there may be auræ of various kinds. Petit mal may be a forerunner of

grand mal or the two may alternate. Between grand and petit mal there

are many grades of epilepsy varying in severity.

=Jacksonian Epilepsy.=—The affection is always symptomatic of lesion in

the motor area of the cortex. The lesion is quite apt to be a tumor,

though various injuries, inflammation, sclerosis, softening, hemorrhage

or an abscess may be the cause. Consciousness is retained and the

convulsions are limited in extent. Tonic and clonic spasms of the same

character as in general epilepsy occur. A slight numbness, tingling, or

twitching may precede the attack.

The =severity= of epilepsy =varies= extremely. The seizure may occur

but once a year or it may occur several times in a day. In many cases

a marked periodicity is observed. The mental functions are not, as a

rule, injured, but when the seizures are frequent, the health fails

and the mental capacity is reduced. Many sufferers from epilepsy are

subjects of chronic gastric catarrh, and have at the same time an

inordinate appetite. Quite frequently a fit may follow inordinate

eating.

When there is a =series= of =convulsions=, which follow one another in

rapid succession and which are associated with high fever, the term

“=status epilepticus=” is applied. The most =common form= of epilepsy

is the =major= form. About two-thirds of all attacks occur between

eight a. m. and eight p. m.

=Diagnosis.=—=Uremic convulsion= closely resembles an epileptic

convulsion. When the history of the case, analysis of the urine,

increased temperature and the general health of the patient are all

closely observed, error should be avoided. In =reflex convulsions= of

=children=, a careful search, and if necessary waiting a short time,

will readily determine the source of the attack. When =nocturnal

convulsions= take place without the knowledge of the patient the attack

is epileptic. In =hysterical convulsions= the patient rarely loses

consciousness. They rarely hurt themselves, never bite the tongue, the

temperature is normal, opisthotonos does not occur, and the duration

is usually longer. In =Jacksonian epilepsy=, the attack is limited to

some portion of the body, or it may gradually extend into a general

convulsion. Care should be taken to recognize petit mal.

=Prognosis.=[121]—Records show that many cases have been cured and a

much larger number have been benefited.

=Treatment.=—Osteopathic treatment has been especially successful in

epilepsy, as compared with other treatment. Although the osteopaths

do not claim a cure in every case, by any means, still about four out

of every ten have been cured, while one-half of the remaining have

been greatly helped in regard to the lessening of the severity of the

attack, and in rendering the attacks less frequent. Conklin through his

special treatment of fasting, dieting, enemata, spinal adjustment, and

particular attention to the large bowel, especially cecum and colon,

has increased this percentage. This is based on several hundred cases.

Important lesions are usually found in the cervical region, from the

third to the seventh vertebra, though they may be as high as the

atlas. These lesions may affect the brain in various ways; probably

in the manner described under the etiology. Lesions are also found in

the dorsal vertebræ and when occurring below the cervical region, the

lesions are generally found in the upper and middle dorsal regions,

though they may be located at any point along the spinal column.

The treatment is according to the rule that applies to all osteopathic

work: an individual correction of the lesions presented in the case at

hand. If any general movement or treatment might be given, it would

be strong traction of the head to stretch the cervical vertebræ, or

rather to separate them, so that the circulation to the brain may be

equalized. Another general measure is to hyperextend the neck with

fulcrum at juncture of atlas and occiput, thus releasing the upper

anterior tissues that may impede cerebral circulation.

If the lesions in such cases are in the cervical vertebræ, probably

they affect the cervical sympathetics. A =careful search= for a source

of excitation must be made throughout the entire body. An irritation

of the intestinal tract may be the exciting cause; or some irritation

of the genito-urinary tract may be found, as phimosis, masturbation,

etc., so that it is very necessary that great care be taken in the

examination. Subjects of masturbation usually present lesions along the

genito-urinary center in the spine. All possible reflex irritations

should be eradicated.

Proper =hygienic measures= should be added. Pay particular attention to

the bowels. Place the patient in the knee-chest position and thoroughly

raise the cecum and ascending colon in order to improve circulation

and promote elimination. Baths are important, and plenty of fresh air

and outdoor exercise are of much significance. The patient’s mind

should be occupied. The question of food is an important one; general

diet—carefully regulated as to the amount given—should be prescribed. A

vegetable diet is usually best. Reduction of salt seems to have a good

effect. The patient must not be allowed to eat too much at a time, nor

too often. If the bromides are being used, they should be withdrawn

gradually.

In most cases of true epilepsy a continued treatment of several months

is necessary. Unless the patient can follow out the treatment for

several months, or even years, in a number of cases it will be entirely

useless to take the treatment; although if the lesion present is very

apparent, and the patient is enjoying fair health otherwise, and has

not been affected long, a treatment for a few months, or even weeks,

might be all that is necessary.

=Surgical interference= may be indicated in Jacksonian epilepsy.

Trephining has been practiced successfully in a number of cases and

the risk from operation with modern surgery is so reduced that one is

frequently justified in advising an operation.

=During= an =attack=, a special treatment cannot be given to lessen the

severity of the fit in all cases; in fact, most patients prefer not to

have the seizure shortened as the after effects are more disagreeable.

In some cases, at the beginning of the seizure, exerting a firm

pressure upon the suboccipital will quiet the patient. This treatment

probably controls the circulation of the brain, by way of the superior

cervical ganglion. In cases where the exciting factor seems to be in

the intestines, and the peristaltic action of the bowels is reversed,

causing a reversion of the nerve current of the vagi, a rapid, firm

kneading over the abdomen, so as to establish normal peristalsis, will

suffice to prevent an attack, if one is notified of its approach. In

some cases a rapid, thorough stimulation of the solar plexus will

lessen an attack. Possibly it reduces the blood pressure in the brain,

by bringing blood to the splanchnic region.

In all cases during the convulsion the patient should be carefully

protected from injuring himself. A towel should be twisted and placed

in the mouth, so that the tongue cannot be bitten. Do not place small

articles as corks, etc., between the teeth, as they are liable to enter

the pharynx and cause suffocation. The patient should be watched to

protect him from any injury; otherwise the attack should usually be

allowed to spend itself.